Provider Demographics
NPI:1437132370
Name:BRENNAN, LISA K (R PH)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:K
Last Name:BRENNAN
Suffix:
Gender:F
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11540 34TH ST SW
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-9744
Mailing Address - Country:US
Mailing Address - Phone:701-225-0557
Mailing Address - Fax:
Practice Address - Street 1:431 W VILLARD
Practice Address - Street 2:THE MEDICINE SHOPPE
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601
Practice Address - Country:US
Practice Address - Phone:701-227-8265
Practice Address - Fax:701-227-8789
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND4461183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND20834Medicaid
ND20834Medicaid